Long-term tolerability of tramadol LP, a new once-daily formulation, in patients with osteoarthritis or low back pain.

INTRODUCTION: Tramadol hydrochloride is a centrally acting analgesic, which possesses opioid agonist properties and activates monoaminergic spinal inhibition of pain. An oral, once a day, sustained release formulation of tramadol is thought to be advantageous compared with immediate release preparations as it prevents plasma peaks associated with increased side-effects of the drug. It may also improve compliance. The purpose of the study was to assess the long-term safety of a new sustained-release formulation of tramadol (tramadol LP) in patients with knee or hip osteoarthritis and in patients with refractory low back pain. STUDY DESIGN: The design was a phase III, open, multicentre, international, tolerability study with tramadol LP at a dose titrated by the patient between 100 and 400 mg once daily, according to the intensity of pain. The treatment was administered for a continuous period of 4 weeks followed by an intermittent intake of 5 months in 204 patients. The safety criteria for evaluation were recording of adverse events, laboratory tests, electrocardiogram, radiography, global tolerability assessed by the patient and the investigators. RESULTS: Long-term use of tramadol LP was reasonably well tolerated. Most of the reported adverse events were expected and occurred within the first month of treatment. Roughly half of the patients (49%) reported adverse events, of which 66% were related to treatment. Gastrointestinal events (nausea and vomiting) were the most frequent. Serious adverse events were reported in 6.4% of patients, from which only two cases were related to treatment. There was no sign of tolerance development and the percentage of patients presenting withdrawal symptoms after the end of treatment was low (6%). CONCLUSION: Long-term treatment with tramadol LP once daily is generally safe in patients with osteoarthritis or refractory low back pain.

Cytotoxic constituents from Plumbago zeylanica.

The bioassay-guided fractionation of the dichloromethane extract of aerial parts of Plumbago zeylanica led to the isolation of beta-sitosterol, beta-sitosteryl-3beta-glucopyranoside, beta-sitosteryl-3beta-glucopyranoside-6'-O-palmitate (1), lupenone, lupeol acetate, plumbagin and trilinolein. Compound 1 showed cytotoxic activity against MCF7 and Bowes cancer cell lines (IC50 113 microM and 152 microM, respectively), beta-sitosterol inhibited Bowes cell growth (IC50 36.5 microM) and plumbagin was cytotoxic against MCF7 and Bowes cells (IC50 1.28 microM and 1.39 microM, respectively).

Pharmacokinetic evaluation of a new oral sustained release dosage form of tramadol.

AIMS: To compare the pharmacokinetic profile of a new modified release formulation of tramadol (Tramadol LP 200 mg, SMB Technology, Marche-en-Famenne, Belgium) with that of an immediate release capsule (Topalgic) 50 mg, Grünenthal, Aachen, Germany) after single and multiple dosing and to assess the potential effect of food on its relative bioavailability. METHODS: The first study had an open, single-dose, three-treatment, three-period, six-sequence, randomised, crossover design with at least a five-day wash-out. The second study had an open, steady-state, two-treatment, two-period, two-sequence, randomised crossover design with at least a seven-day wash-out. Both studies contained 30 healthy subjects. Both enantiomers of tramadol and O-demethyl-tramadol (the only active metabolite of tramadol) were assayed in the plasma using an LC-MS/MS method. AUC infinity, AUCt, Cmax, Tmax, and T1/2 were estimated. Statistical analysis was performed using univariate anova, the Wilcoxon nonparametric method or Friedman's nonparametric anova where appropriate. RESULTS: Tramadol had a significantly lower Cmax and longer Tmax than the conventional formulation. Thus, the mean (+/- sd) Cmax of tramadol were 646 +/- 192 and 300 +/- 94 ng ml-1 for Topalgic 4 x 50mg and Tramadol LP 200 mg, respectively (95% confidence interval on the difference expressed as a percentage 42-51). AUC of tramadol from both formulations was comparable (similar AUC infinity and AUCt). Thus, the mean AUC infinity of (+/-)tramadol obtained after multiple dosing were 4611 +/- 1944 and 5105 +/- 2101 ngh ml-1 after Topalgic 4 x 50mg and Tramadol LP 200 mg, respectively (95%CI 102-123%). We also demonstrate that the pharmacokinetics of the drug are not influenced by the intake of food. Thus, the mean AUC infinity of (+/-) tramadol were 5444 +/- 1637 and 5169 +/- 1580 ngh ml-1 after Tramadol LP 200 mg given in the fasting and fed states, respectively (95%CI = 88-103%). CONCLUSIONS: The new sustained release form of tramadol exhibits adequate properties for once a day administration. Furthermore, its pharmacokinetic profile is not affected by the intake of food.

Treatment of acute diarrhoea: update of guidelines based on a critical interuniversity assessment of medications and current practices.

Further to a thorough analysis of the problem of acute diarrhoea and the therapeutic options, recommendations were defined following a multidisciplinary approach. These guidelines take into account the reality of frequent self-medication. They further differ as a function of age (children, primarily treated by ORS and for whom self-medication is not advised versus adults who can self-medicate), symptoms (uncomplicated diarrhoea versus dysentery) and location where the diarrhoea is contracted (at home or when travelling).

[Cardiotoxicity of 5-fluorouracil: report of 6 cases]. / Cardiotoxicité du 5-fluorouracil: à propos de 6 nouveaux cas.

5-fluorouracil (5-FU), a fluoropyrimidine antimetabolite, is widely used in the treatment of cancers of the digestive tract and breast. The clinical cardiotoxicity of 5-FU was first reported in 1975. Adverse cardiac effects include coronary disorders, heart failure and sudden death of suspected cardiac origin. Six new cases are reported, including 5 cases of angina and one of heart failure. The patients, 4 males and 2 females, were 26 to 71 years of age (mean: 56.2). They had no medical history of heart failure, myocardial ischemia or electrocardiographic anomalies prior to 5-FU treatment. Three patients had hypertension of whom one had had type-II diabetes mellitus for the past 20 years. Clinical symptoms included chest pain in 4 patients and heart failure in one, whereas the last patient had ECG changes with no associated clinical symptoms. Clinical symptoms of angina totally disappeared after the cessation of 5-FU administration, but heart failure was alleviated only after the introduction of digitalis, a converting-enzyme inhibitor and a diuretic. It has been estimated that 1.6% of patients treated with 5-FU develop adverse cardiac effects. Patients at greater risk are those with a history of ischemic cardiac disease, thoracic radiotherapy or high-dose 5-FU therapy. The mechanism involved is not clearly elucidated. Spasms of the coronary arteries or toxic inflammation of the myocardium have been suspected. These 6 new cases confirm the potential for cardiotoxicity of 5-FU and the need for careful cardiac monitoring of treated patients.

A reappraisal of the potential chemopreventive and chemotherapeutic properties of resveratrol.

Resveratrol, a phytoalexin found in grapes and wines, has been reported to exhibit a wide range of pharmacological properties and is believed to play a role in the prevention of human cardiovascular disease (the so-called 'French paradox'). This molecule may also play a major role in both cancer prevention and therapy. In this review article we summarize the recent advances that have provided new insights into the molecular mechanisms underlying the promising properties of resveratrol. These include cyclooxygenase, nitric oxide synthase and cytochrome P450 inhibition, as well as cell cycle effects, apoptosis modulation and hormonal activity.

Characterization of TNP-470-induced modifications to cell functions in HUVEC and cancer cells.

The aim of the present work is to characterize (both in vitro and in vivo) the influence of TNP-470 on different cell functions involved in angiogenesis and, more particularly, on endothelial cell growth, cell migration and vessel formation. In addition, a possible direct anti-tumor activity was investigated. To this end, we made use in vitro of human umbilical cord endothelial vein (HUVEC) cells and two human cancer cell lines. The TNP-470 effects on the growth of cancer cell lines were compared to those of Taxol (an inhibitor of microtubule depolymerization), a cytotoxic reference which also displays strong antiogenic activity at low (non-toxic) doses. The in vitro effects were characterized on the mouse mammary MXT adenocarcinoma, on which we also characterized the influence of three clinically active anti-tumor compounds (as cytotoxic references). The purpose of this part of the study was to determine the actual TNP-470-related anti-tumor activity and to evaluate the possible toxic side-effects at the doses at which this compound induces tumor growth inhibition. These investigations were completed by analyzing the TNP-470 effects on HUVEC cell motility and in vitro and in vivo vessel formation. The results show that in vitro, TNP-470 inhibited the growth not only of HUVEC, but also of neoplastic cells. Furthermore, TNP-470 clearly inhibited in vitro endothelial cell motility (p<10(-5)). However, it had only a minor effect (p=0.02) on the formation of HUVEC cell networks on Matrigel(R). In vivo, TNP-470 was able to inhibit tumor growth (on the MXT model) at a dose (50 mg/kg) associated with toxic side-effects. Histological examination showed a significant inhibition of vessel formation (p<0.001) at high (toxic) and intermediary (non-toxic) doses (50 and 20 mg/kg). However, we also observed that TNP-470 stimulated lymphocyte proliferation. Thus, care must be taken with the TNP-470 compound in combination with other anti-tumoral agents in order to avoid certain unfortunate clinical complications.

In vitro and in vivo pharmacological characterizations of the antitumor properties of two new olivacine derivatives, S16020-2 and S30972-1.

S16020-2, a new olivacine derivative and a topoisomerase II inhibitor, has recently entered clinical trials. New analogues and derivatives have been synthesized from the S16020-2 compound. Preliminary data indicate that S30972-1, one of these S16020-2 derivatives, may exhibit a comparatively higher level of antitumor potency associated with an improved therapeutic index than does S16020-2. The antitumor activities of S16020-2 and S30972-1 were therefore characterized both in vitro and in vivo, with Adriamycin and etoposide chosen as reference compounds. The in vitro data show that S30972-1 is a topoisomerase II inhibitor, mediating its activity through an ATP-dependent mechanism such as S16020-2. The two olivacine derivatives exhibited similar activities in vitro at the levels of the global growth of six human cancer cell lines, of the induction of apoptosis, and of the G2 cell cycle phase arrest. The in vivo antitumor activity characterization included the use of two murine leukemia types (P388-LEU and L1210-LEU), two murine lymphoma-like models (P388-LYM and L1210-LYM), two mammary adenocarcinomas (MXT-HI and MXT-HS), and one melanoma (B16). The data show that S30972-1 is actually more efficient in vivo than S16020-2, a feature that may relate to the fact that S30972-1 is less toxic than S16020-2. The S30972-1 compound exhibited in vivo a level of antitumor activity that was also actually higher than that exhibited by Adriamycin and similar to that exhibited by etoposide.

In vitro/in vivo characterization of a tramadol HCl depot system composed of monoolein and water.

Various monoolein-water systems containing tramadol HCl, a potent analgesic, were formulated to obtain sustained-release dosage forms which could be administered by subcutaneous, intramuscular or intrathecal injections. They were examined for their in vitro drug-release profiles and in vivo analgesic properties in rats in a 14 h period following intramuscular administration. In order to obtain a lower viscosity, we have substituted a part of monoolein by oleic acid and phospholipids. Both binary (monoolein-water) and quaternary (oleic acid-phospholipid-monoolein-water) formulations exhibited controlled drug-release profiles which were accelerated by surfactant adjunction. This surfactant action was probably due to structural changes in the lipid arrangement and was much more pronounced for the modified formulations. According to the results obtained in vitro, formulations with slower drug release (i.e. the native formulation and the modified one without surfactant) were selected for assessment of their in vivo properties. Both formulations demonstrated prolonged analgesic activities in the rat tail flick test manifested by stable pain relief during more than 10 h compared with the 3 to 4 h analgesia obtained with the commercially available tramadol HCl solution. The sustained-release capabilities were evaluated by using a modified half value duration (HVD) ratio and all sustained-released formulations exhibited a HVD ratio equal or superior to 3.9.

Homocamptothecin, an E-ring-modified camptothecin, exerts more potent antiproliferative activity than other topoisomerase I inhibitors in human colon cancers obtained from surgery and maintained in vitro under histotypical culture conditions.

Topoisomerase I (Topo I) is overexpressed in cancer colon tissues compared with normal colon tissues. Several anti-Topo I inhibitors are already successfully used in the clinic. We illustrate here the antiproliferative activity of a new class of Topo I inhibitors, i.e., E-ring-modified camptothecins with enhanced lactone stability (L. Lesueur-Ginot et al., Cancer Res., 59: 2939-2943, 1999). Forty-three human colon cancers were obtained from surgical resection and maintained under organotypical culture conditions for 48 h. Cell proliferation was assessed in these ex vivo tumor tissue cultures by tritiated thymidine autoradiography. As a validation of the methodology, we first analyzed in our model the antiproliferative activity of two clinically active topoisomerase II (Topo II) inhibitors, Adriamycin and etoposide, which are not active for colon cancers; and three Topo I inhibitors, camptothecin (CPT) and two clinically active compounds (especially for colon cancers), i.e., topotecan and the active metabolite of irinothecan, SN-38. We then compared the antiproliferative activity of CPT, topotecan, and SN-38 against those of two investigational E-ring-modified camptothecins, i.e., BN80245 and BN80915. Three concentrations (1, 10, and 100 nM) were studied for each compound. The results indicate that the three Topo I inhibitors used as references, i.e., CPT, irinothecan, and SN-38, were much more active than the two Topo II inhibitors, i.e., Adriamycin and etoposide, with SN-38 being the most efficient. The two investigational compounds BN80245 and BN80915 exerted higher antiproliferative activity than the three anti-Topo I reference compounds, with the highest activity observed for BN80915.

Mechanisms of tumor angiogenesis and therapeutic implications: angiogenesis inhibitors.

Angiogenesis is the development of new blood vessels from the existing vascular bed. In normal conditions this tightly regulated process occurs only during embryonic development, the female reproductive cycle and wound repair. In contrast, in pathological conditions such as malignant growth, atherosclerosis and diabetic retinopathy, angiogenesis becomes persistent due to an imbalance in the interplay between the positive and negative regulatory signals controlling the process. Thus, the control of tumor neovascularization may lead to new therapeutic approaches. Indeed, several anti-angiogenic drugs are currently undergoing preclinical characterization and/or clinical investigation. Recent achievement has clarified the mechanisms of action leading to pathological angiogenesis and has highlighted the role of hypoxia, growth factors, growth factor-receptors, enzymes and cell adhesion molecules involved in the process. This knowledge has permitted the design of receptor antagonists, adhesion molecule blockers and new targeted vascular approaches including gene therapy.

Characterization of biological features and chemosensitivity of a new experimental lung metastasis model originating from the MXT mouse mammary adenocarcinoma.

The present study shows how an original mouse metastatic lung model was established from the MXT mammary adenocarcinoma. This metastatic model was obtained by injecting the C/MET clone into the tail veins of B6D2F1 mice. The C/MET clone corresponds to one of eleven cell clones that were isolated in vitro from the MXT model. Of these 11 clones, only the C/MET leads to lung metastatic tumor development when injected i.v. into mice. Furthermore, the C/MET clone colonizes the lung only. The present data show that the C/MET metastatic model and the MXT parental line are weakly (if reference is made to the P388 leukemia model) sensitive to adriamycin, clyclophosphamide and etoposide. However, under specific experimental conditions, the chemosensitivity of the C/MET model can be significantly increased. The C/MET model therefore appears to be an interesting pharmacological tool to test new investigational agents with anti-tumor potentialities to lung metastases.

DNA topoisomerase targeting drugs: mechanisms of action and perspectives.

The nuclear enzymes DNA topoisomerases I and II appeared as cellular targets for several antitumor drugs: campthotecin derivatives interacting with topoisomerase I, and actinomycin D, anthracycline derivatives, elliptinium acetate, mitoxantrone, epipodophyllotoxine derivatives, amsacrine and a new olivacine derivative, NSC-6596871 (S 16020-2), which interact with topoisomerase II. The functions of these enzymes are numerous and important since they are critical for DNA functions and cell survival. Despite the fact that they share the same target, topoisomerase II inhibitors have different mechanisms of action. Two principle types of induced alterations are involved in cellular resistance to topoisomerase II drugs: qualitative or quantitative alteration of the enzyme and/or increased drug efflux due to overexpression of P-glycoprotein. S 16020-2, a new olivacine derivative with a high antitumor activity against solid tumors, shows a potent cytotoxic effect against tumor cells expressing P-glycoprotein. This observation suggests that the comprehension of the respective effects of topoisomerase inhibitors and the precise knowledge of their mechanisms of resistance would improve the use of this therapeutic class in the clinic within rational chemotherapeutic combinations.

[Treatment of pain at a community pharmacy]. / Le traitement de la douleur dans le cadre de l'officine.

The first part of this article deals with the physiology of pain. We focus on the different pathways of pain. Two main mechanisms of pain control are described, namely peripheral control, by the supraspinal gate and central or supra-medular control. Three different mechanisms can induce pain. We focus on pain perception by excess of stimuli and desafferent ways of pain. The following part deals with the different kinds of pain presented to the community pharmacist. At the end we discuss the treatment of pain, describing the pharmacological aspects of the three most important "Over The Counter" molecules, namely paracetamol, aspirin and ibuprofen. Also some combinations of analgesic agents and adjuvants are discussed.